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Medical Director, CalAIM

Job Category:  Management/Executive
Department:  Health Services
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  7992

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The California Advancing and Innovating Medi-Cal (CalAIM) is a new state-wide CMS Medicaid waiver that seeks to expand care management support and community-based social services for vulnerable and qualified Medi-Cal beneficiaries in the community setting.   The CalAIM waiver program specifically seeks to support those who are high utilizers of the health system, are homeless, have behavioral health, substance use service and/or complex medical needs.  In the future, we are also expected to support those who are discharged from the correctional systems.   The CalAIM Medical Director (Medical Director) will assume a key medical leadership role in the organization to help with the programmatic development as well as ensuring that the programs align with our operational systems and tools while also performing utilization reviews of cases. 

The Medical Director will report to the Chief or Deputy Chief Medical Officer. This position  will work closely with our CalAIM team as well as with the  Behavioral Health, Care Management, Compliance, Provider Network, Social Services, Utilization Management and many other internal L.A. Care Departments. The Medical Director is also responsible for supporting the development and implementation of clinical protocols and policy and procedures and ensure that they are aligned with the regulatory and contractual requirements as well as ensuring that it aligns with our internal core systems, workflows and processes.  This job will also entail a fair bit of network development and relationship building with the community based social services as well as supporting our oversight team when needed.  Additionally, the Medical Director will also be critical with the collaborative work and education to our delegated medical groups and plan partners (Anthem Blue Cross, Blue Shield/Promise and Kaiser) and ultimately help cascade the CalAIM referral process and eligibility criterial information down to our various provider networks.
 

Duties

Provides and oversees the delivery and quality assurance of traditional utilization management services and resources, consisting of prior authorization, retro review, and concurrent review; oversight, support and relationship management with our delegated medical groups and plan partners (Anthem Blue Cross, Care 1st and Kaiser). 

Provides clinical and programmatic direction and oversight of both direct and delegated UM functions for high value care and consistent with regulatory requirements.   

Provides  leadership as L.A. Care begins to further develop and implement critical strategies around care coordination, transitions of care and out of network/out-of-area coordination of services.   

Works closely with the CalAIM team and be part of the overall leadership and management accountability matrix as it relates to the  program development and implementation, provider engagement.  Responsible for the oversight and evaluation of the program.  

Applies the necessary skills (clinical, operational, strategic, provider engagement  to ensure that the programs are successful for our vulnerable eligible members and providers, and  also ensure that the program and its participants meet the regulatory and contractual requirements as intended by CMS and DHCS.                                                                                  

Performs utilization review of cases and participate in our care management programs periodically.  Provides utilization review and call coverage on scheduled  weekends and holidays on a rotational basis.

Performs  utilization reviews and determinations;  and address grievance and appeals, and State Fair Hearings and periodically attend the inter-disciplinary case conferences with our Care Management teams.  

Collaborates and partners with hospitals, Federally Qualified Health Centers, primary care practices, and the L.A. County Departments of Health Services, Mental Health, Public Health) and community based organizations and other key partners.  Conducts virtual and on-site visits with our community partners when needed., 

Performs other duties as assigned.

       

Education Required

Doctor of Medicine (M.D.)

Education Preferred

Experience

Required:
At least 8 years of clinical medicine experience after medical school.

Demonstrated experience working in a collaborative or matrix relationship

Experience in maintaining liaison with Federal, State, and local bodies and medical organizations.

Preferred:

Physicians with social service experience in governmental programs, social service organizations (e.g. homeless or supportive housing), justice-involved, diversion and re-entry programs and/or other non-health care related organizations.  

Experience with working for underserved, safety net populations including those who are homeless, persons with disabilities, seniors, foster children and youths and those of various ethnic and cultural backgrounds.

Demonstrated history working with community groups and organizations.   

Demonstrated experience in developing and implementing and/or evaluating programs, policies and procedures.
 

Skills

Required:
Demonstrated ability to provide leadership to physicians, nurses, and other health care and non-health care professionals, and an interest and involvement in the affairs of the health care and social service communities.

Demonstrated ability for teamwork and collaborative problem-solving.

Possess strong analytic ability. 

Excellent written and verbal communication skills, negotiating skills, consensus building and teamwork, planning and implementation skills.

Demonstrated ability in public relations including effectiveness in working with community groups and organizations.

Understanding and experience with homelessness, children with complex medical conditions, justice-involved populations who have significant clinical needs, and the growing age population.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information

Preferred Additional Education: 
Master's Degree in relevant Medical or Public Health disciplines  and/or Social Service Degree or Certificates that may be applicable for the CalAIM programs..

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Social Services, Behavioral Health, Public Health, Medical, Medicaid, Service, Healthcare

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